STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT DOMESTIC ABUSE AFFIDAVIT Plaintiff Civil Action File Number Defendant I, ___________________________________________________, on oath do depose and state as follows. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Name of the Plaintiff _____________________________________________________________________________ Signature State of _______________________________ County of _____________________________ On this ________ day of ________________, 20____, before me, the undersigned notary public, personally appeared _____________________________________________________ personally known to the notary or proved to the notary through satisfactory evidence of identification, which was _____________________________________________________, to be the person who signed above in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: ____________________________________ My commission expires: ____________________________ Notary identification number: ________________________ DC-57 (revised November 2014) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT DOMESTIC ABUSE AFFIDAVIT Plaintiff Civil Action File Number Defendant Continuation page if needed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DC-57 (revised November 2014) American LegalNet, Inc. www.FormsWorkFlow.com